A new study presented at the 2013 Clinical Congress of the American College of Surgeons suggests that the presence of a biomarker for poor nutritional status before the operation doubles the risk of complications among patients with bladder cancer who undergo a radical cystectomy procedure.

Surgeons from the University of North Carolina School of Medicine, Chapel Hill, identified a potentially modifiable risk factor for such postsurgical problems: a low preoperative level of albumin, a marker of the protein level in the blood. David C. Johnson, MD, MPH, lead author of the study and a third-year urology resident at UNC School of Medicine, and colleagues evaluated the impact that patients' nutritional status before radical cystectomy had on the rate of complications within 30 days after the operation.

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Radical cystectomy is a procedure that involves surgical removal of the bladder and lymph nodes. Researchers mined the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database to analyze postoperative complications data from 1,085 patients who underwent radical cystectomy at 315 medical centers across the United States from 2005 to 2011. ACS NSQIP is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of care in private sector hospitals. Bladder cancer will be newly diagnosed in more than 72,500 people this year, the American Cancer Society estimates, and about one-third of all cases involve cancer that has spread into the muscular wall of the bladder, which permits spread to other organs.* For these patients, radical cystectomy is the standard treatment, but the complication rate after the operation remains high, particularly for infections and poor wound healing, explained study authors.

"Poor nutrition is a known risk factor for adverse results after radical cystectomy," Dr. Johnson explained. "The prevalence of nutritional deficiency is very high in patients with bladder cancer, partly because of their disease and partly because of their advanced age—73 years on average." Among study patients who experienced complications within the first month after the surgical procedure, the authors looked for the presence of any of three known preoperative nutritional factors that could affect surgical results. These factors were a low albumin level (less than 3 grams per deciliter, or g/dL), weight loss greater than 10 percent of body weight six months before the operation, and obesity, defined as a body mass index (BMI) of 30 kilograms per square meter or higher.

Study results showed that 575 patients (53 percent) experienced complications within the first month after the surgical procedure. Of these patients, 32 (6 percent) had a low preoper-ative albumin level, 28 (5 percent) had major weight loss within the six months before the operation, and 182 (32 percent) were obese at cystectomy. The investigators found that only low albumin level was a significant predictor of experiencing a postoperative complication, after controlling in the statistical analysis for patient age, involvement of a trainee surgeon in the operation, the year the operation took place, and a history of a prior operation.

Patients with low albumin levels before the surgical procedure had 2.1 times the risk of having a complication within 30 days after the operation compared with those whose albumin level was in a normal range or above (3 g/dL and higher), the authors reported. It is unclear from this study whether preoperative correction of low albumin levels, such as from nutritional supplementation, will translate to fewer problems after radical cystectomy. However, based on their findings, Dr. Johnson still recommends that patients whose albumin levels are low before a scheduled radical cystectomy see a nutritionist to learn whether they need to make dietary changes before their operations. "There's very little risk in improving nutritional status before the operation and signifi-cant possible benefits," said a study coauthor Angela Smith, MD, an assistant professor of urology at UNC.

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